AIDS AND AFRICA
Le Monde Diplomatique January 2001
Aids has exacted a terrible toll over the past 20 years: 19m dead and 35m people with HIV. In the North multitherapies have reduced mortality though the treatment does not always keep the disease at bay long-term. And it costs a lot. Too much for the South, it was claimed, until the world conference in Durban in July 2000. There, associations pointed to the responsibilities of pharmaceutical multinationals and helped loosen the stranglehold stopping companies producing cheaply the generic molecules involved. But shaky regimes, war, migration and prostitution all contribute to the continued growth of Aids.
by DOMINIQUE FROMMEL *
The great epidemics have always been seen as coming from elsewhere, and
Aids has been no different. Before Africa came to be seen as its cradle and
some countries demanded a test for HIV (human immunodeficiency virus)
before they would grant entry visas, the United States had pointed the finger
at Haitians as a particularly exposed group. In the third world, which for a
time denied its existence, Aids has been represented in various ways - as a
virus that had escaped from laboratories in America and was going to
decimate the native populations, and then, as the drama grew, as a scourge
afflicting specifically sub-Saharan Africa. For a number of years India, too,
hushed up the HIV threat.
After the explosion of Aids in the US the disease was looked for, and found,
all over the world. The situation was most tragic of all in sub-Saharan Africa,
where it affected equal numbers of men and women; in urban areas more than
10% were seropositive in the 15-49 age-group which includes economically
and sexually active adults (1). There were almost none among older people,
proof that the virus had spread in recent years.
Thunderstruck, the international community launched a concerted aid effort in
1985. Under the aegis of the World Health Organisation (WHO), national
Aids control programmes were set up to coordinate all activities connected
with the disease in each country. Because of the urgency with which this was
done, however, these programmes are in most cases not part of the general
health administration, but have been attached directly to health ministries. As a
result, the action they take is seldom integrated into national systems for
delivering health care.
At first the work of the national programmes, led by foreign experts, focused
on epidemiology (2), on the safety of blood transfusions and on prevention
campaigns based on WHO's "information, education and communication"
(known as the IEC model), which had been geared to circumstances in the
western world. Surveys by the national programme centres quickly confirmed
that, in Africa and Asia, HIV transmission was essentially heterosexual, and
showed that genital infections - which were present everywhere and left
untreated - greatly increased the risk of contagion.
Prevention campaigns targeted the groups at risk: prostitutes (though not their
customers), patients presenting with sexually-transmitted diseases, long-haul
truck drivers and, in Asia, drug addicts (3). Among populations with a high
level of HIV infection, these moves have not stemmed the progress of the
disease. Instead, they have tended to push Aids into the private area of the
"shameful diseases" one does not talk about - the very opposite of making
everyone aware of the danger.
In an international mobilisation of effort, specialists from the North decided
the operational goals, gathered data and examined the results. For a long
while this led to national bodies staying in the background. They saw the
epidemic not as a major public health problem the nation's politicians had to
do something about, but as a highly complex medical problem that could not
be overcome without outside help.
The West's scientific predominance, by taking legitimacy away from the
national bodies involved and skewing their professional thinking, in fact
encouraged the politicians' vacillation and procrastination.
A further hammer-blow, structural reorganisation, forced cutbacks in health
budgets. And the continued existence of conditions that can be prevented or
cured - malaria, measles, malnutrition, tuberculosis, the diarrhoeal diseases
and maternal and infant mortality - made it hard to bring in any reform of the
health system that would meet the population's basic needs and still give
priority to preventing the spread of HIV and looking after those with Aids (4).
Reluctance to talk
A strong community-based sector has developed in the countries of the South
in health matters; but in an area symbolised by sex and blood, it has not
acquired the scope of its counterparts in the North, where pressure groups
have had a great influence on their country's health policy. For all the parties
that are involved and all the resources that have been poured into information
campaigns, and despite the contacts forged between the health professionals
and community movements and religious leaders, there is still a reluctance to
talk about the subject. This stands in the way of a public debate on the Aids
When the scientific community of the rich countries took charge of the health
aspect of the fight against Aids in the countries of the South, it was doing so in
line with the principles of solidarity in which the West believed. By highlighting
the relationship between poverty and the way HIV was transmitted, the
epidemiologists shook the certainties of the Unaids "consortium", which takes
in the UN agencies and the World Bank. For the intelligentsia in their New
York and Geneva offices, responsible for strategies to stem the tide of Aids,
the realisation that biomedical means were not, on their own, going to make it
possible to beat Aids came as an ordeal - one that at all costs must not be
reflected and tragically amplified in the countries of the South. Other factors
came to light that let them off the hook: underlying the shortcomings that had
been found, there was a lack of understanding of the sexual mores of the
populations of the South.
A new component of studying and acting on people's behaviour was added to
the programmes. There again, local researchers had no choice but to put
themselves under the guidance of the expatriates running the projects. Studies
like this involve more unforeseens than the biomedical approach. For one
thing, one is delving into innermost feelings and urges, and coming up against
individual and collective modesties and susceptibilities. And for another, what
the social anthropologists discover is often not what politicians and institutional
decision-makers like to be told. But is unravelling the many factors -
physiological, psychosocial, cultural and economic - that determine sexual
mores essential for suggesting behaviour compatible with avoiding HIV
infection? The social anthropologists may have forgotten that in the South
today's falling birth-rate has not followed large-scale enquiries, but results
mainly from access to education and health-care.
The research done by Unaids, coupled with the experience of WHO and
Unicef in the field of human reproduction, will undoubtedly provide data that
will help to show how diverse sexuality is. Can all this information pinpoint the
motives that will lead men and women, once warned of the risk of HIV, to
change their behaviour and sexual practices? Or will it just lead to pointless
arguments that conceal the scale of the social and economic factors standing
in the way of changes in behaviour (5)?
'Information, education and communication'
If we look at how reluctant Westerners are (for all their exposure to the
notions of psychoanalysis) to talk about their sex life, we can see the size of
the problem of bringing a discussion of sexual relations into the IEC
campaigns. These populations already find it hard to take in, understand and
discuss the usual messages put over by IEC, marked as they are by a medical
rationale. So the emotional factors stirred up by any mention of sexuality may
make a real debate within communities about Aids even more unlikely.
The greatest explosion of Aids has been in southern Africa. The lack of
prevention programmes among the deprived populations led President Thabo
Mbeki to convene a conference bringing together a panel of experts to restate
the principles for combating Aids in the South (see article by Anatole Ayissi).
One may hope that media coverage of the many controversies this has
sparked off will break the taboos that have been muffling the voices of the
victims, of their families and of those who think that Aids is someone else's
One of the essential conditions for harnessing the efforts of the people in the
grip of Aids is their being able to talk openly with those close to them, without
fear of reproaches or reprisals. For women, it means being able to protest at
the unequal standards applied to men and women (in particular the little say
they have in whether to have sex or not). It means condemning the expelling
of young girls before they have finished their schooling; pointing out that
invoking their rights is still just reciting so many empty words; and complaining
that out-of-date schoolbooks still glorify male virility. For the young, it means
stopping making fun of the slogan "I won't be an Aids victim" while, for them,
the risk from sex is just one among so many others. For those running the
national Aids control programmes, it means not looking at the disease just in
the way they have been taught, but with their own eyes and from a different
angle. Only by speaking out freely and forcefully will initiatives get going that
fit in with the way people live their lives; and these initiatives will do a great
deal more for the anti-Aids strategy than using the new antiretroviral drugs to
Many of the organisations formed to represent the victims are indignant at the
exorbitant prices charged for active HIV treatments that are used in the North
but are out of reach for those in the South. Demanding access to treatment for
everyone, and by every means, they denounce those who advocate "putting
everything into prevention", which they describe as "a self-interested policy
leading nowhere" (7). Amid all this argument, the job of the doctor in a rural
health care centre is far from easy.
He is aware that an epidemic cannot be controlled with drugs alone. He also
realises that if he does not provide treatment, he is foregoing the incentive for
people to come voluntarily for counselling and voluntary testing - the
mainspring for preventing them from becoming infected with HIV. Yet faced
with Aids, he cannot build on the experience he has gained in dealing with
tuberculosis, a curable disease with a well-codified scheme of treatment.
Making sure that anti-TB treatment is taken properly and regularly is an uphill
task. On the one hand the doctor has to gain the patient's confidence, and
convince him he will be cured in under a year if he is scrupulous in taking the
drugs as prescribed. Very many patients, however, feel better after a few
weeks and discontinue their treatment, thus putting those around them at risk.
On the other hand, the escalation in new cases makes running out of stock of
the drugs a nightmare for the health services (8).
The same kind of operational problems stand in the way of introducing
specific treatment for Aids. In the towns, only a few centres have staff trained
to deal with Aids patients and their family and social problems; and few have
the infrastructure needed to carry out the many tests needed for successfully
completing treatment that makes heavy demands and often has unpleasant
side-effects. Out in the countryside, these resources do not exist at all - a fact
that makes access to anti-HIV drugs premature anyway. Treatment that is not
followed properly or interrupted is of little benefit to the patient, and increases
the serious risk of resistant strains of the virus emerging. At present, the
priority in using antiretrovirals is to prevent mothers passing HIV on to their
newborn babies. The treatment is for a limited time, and costs no more than
the usual vaccinations.
One sign of hope is in the success achieved by bringing preventive action into
the programmes for caring for patients. Uganda, for instance, which opted for
providing information individually to its population and enjoyed firm support
from its head of state and the involvement of a number of ministries, has seen
the rate of new HIV infection drop by almost half within five years. Resisting
the siren calls of the short-term solution (the resort to antiretrovirals, which
mean treatment for life) (9), training health staff better in prevention work,
improving working facilities and reaching the whole of the population are
approaches all very much to the point.
In the public debate, the health professional - who needs to keep up the
community's confidence in the health service, imperfect as this may be - has
little room for manoeuvre.
The title for the 13th international conference on Aids held in July 2000 in
Durban was "Break the silence". Ambitious advice, to which some are still
immune. It is no longer enough to criticise the governments of the South for
their lack of commitment, and the UN agencies for being involved in words
rather than deeds. The deadly menace hanging over Asia and eastern Europe
can no longer be ignored in the way the frightening forecasts of the spread of
Aids in Africa were back in 1990.
Going beyond the individual cultural and scientific factors that hold back the
fight against Aids worldwide, it must be recognised - more forcefully than the
UN Security Council did on 20 January this year - that Aids is a symbol of
the economic imbalance ravaging our planet. It is a tragedy for all who are
denied their human rights and are thus peculiarly vulnerable to Aids infection.
It is a scandal because of the blinkered views of the financial powers in both
the North and the South (10).
There is one path to eradicating the causal agent, HIV - a vaccine. The
scientific challenge of producing it is, it seems, at last being met. Bringing it
into use, planned for 2007, will demand redoubled efforts in financing and in
education and information - and that means organising public debate.
Eliminating the predisposition to Aids, like that to other plagues, will come
through a long process of social change. And unless the silence that shrouds
the inequality of access to resources of every kind, including medicine, is
broken, this other and bigger challenge cannot be met.
* Dominique Frommel is a doctor, carrying out research at the French National Institute
for Health and Medical Research (Inserm).
(1) In southern Africa the incidence was over 20% in 1999.
(2) Epidemiology studies the occurrence, distribution and determining factors of health
and illness in populations. Its aim being to identify the causes of health problems,
modern epidemiology seeks to uncover the socio-economic obstacles to health. See
Didier Fassin, "Entre politiques du vivant et politiques de la vie. Pour une anthropologie
de la santé", Anthropologies et Sociétés, Quebec, January 2000.
(3) For an analysis of the situation in French-speaking Africa, see Marc-Eric Gruénais,
Karine Delaunay, Fred Eboko, Eric Gauvry, "Le sida en Afrique, un objet politique",
APAD Bulletin (Euro-African Association for the Anthropology of Social Change and
Development, D-55099 Mainz), 1999, vo. 17. See also Jean-Pierre Dozon and Didier
Fassin, "Raisons épidémiologiques et raisons d'État. Les enjeux sociopolitiques du sida
en Afrique", Sciences sociales et santé, February 1989.
(4) Josef Decosas, "Fighting Aids or responding to the epidemic: can public health find
its way", The Lancet, 7 May 1994, and Dave Haran, "Africa: do health reforms recognise
the challenge of HIV?", The Lancet, June 1997, supplement III.
(5) Basil Donovan, Michael W Ross, "Preventing Aids: determinants of sexual
behaviour", The Lancet, 27 May 2000.
(6) See Martine Bulard, "The apartheid of pharmacology", Le Monde diplomatique
English edition, January 2000. A further denial of appropriate health care comes through
the emigration to the industrialised countries of doctors trained in the countries of the
(7) "De quelle guerre parle-t-on?", Act Up-Paris, Le Monde, 29 January 2000.
(8) Every year some 8m new cases of TB are reported, and more than 2m patients die of
(9) Gifts of drugs, in parcels with labels identifying the donors, are not a long-term
(10) In 1998 the African governments spent $6bn on buying arms and $15m on fighting
Aids. In the same year, official aid to anti-Aids programmes in the countries of the
South amounted to $160m, and the US National Institute of Health had allocated 10% of
its budget - $180m - to the vaccine project.
Translated by Derry Cook-Radmore
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